J. Maxillofac. Oral Surg. DOI 10.1007/s12663-013-0550-3
REVIEW PAPER
The Benefit of the Smartphone in Oral and Maxillofacial Surgery: Smartphone Use Among Maxillofacial Surgery Trainees and iPhone Apps for the Maxillofacial Surgeon Elinor Carey • Karl Frederick Braekkan Payne Nabeela Ahmed • Alexander Goodson
•
Received: 7 March 2013 / Accepted: 29 June 2013 Ó Association of Oral and Maxillofacial Surgeons of India 2013
Abstract The use of smartphones has soared among healthcare professionals in recent years, with estimated figures reporting that the majority of clinicians own and use smartphones in the workplace. Smartphones allow the clinician to carry textbooks in their pocket, write documents on the move and use email and internet to enhance productivity and clinical decision making. These advances in smartphone technology have enabled access to healthcare information for the clinician and transfer of data between team members, giving rise to the phenomenon of telemedicine. With the ability to instantly transfer clinical data to the off-site surgeon, combined with purpose-built medical apps, the smartphone is rapidly becoming an invaluable tool for the modern surgeon. Many studies have linked the benefits of smartphones and apps in other surgical specialities, but no article to date has highlighted the merits and full scope of this technology to the Oral and Maxillofacial Surgeon. We report that 94 % of British maxillofacial surgery trainees own a smartphone, with 61 % owning an iPhone. 89 % of trainees questioned had downloaded medical apps and used them regularly during clinical activities. We discuss the clinical application of the smartphone in the field of oral and maxillofacial surgery and review a list of useful and relevant apps for the modern maxillofacial surgeon using the iPhone as an example platform. Keywords Smartphone iPhone Application App Oral and maxillofacial surgery OMFS
E. Carey (&) K. F. B. Payne N. Ahmed A. Goodson Department of Oral & Maxillofacial Surgery, King’s College Hospital, London, UK e-mail: [email protected]
Introduction A smartphone is a category of mobile device that provides advanced capabilities beyond a typical mobile phone. Smartphones have a complete operating software system that provides a standardised interface and platform for application developers. They allow users to carry a mobile phone, games console, music player, camera, calendar and internet browser all in one small handheld device, with their limitations governed only by the types of applications (apps) downloaded onto them. The smartphone is now omnipresent among the general public and has rapidly permeated into healthcare, with recent studies estimating that over 80 % of doctors own a smartphone [1]. Evidence is growing to support the use of smartphones in the clinical setting, with benefits demonstrated as an electronic educational resource, in clinical decision making support and in the prevention of medication errors [2]. As an enhanced communication tool, studies have reported that smartphones were strongly preferred over any other form of hospital colleague–colleague communication. Improvements were seen in efficiency, ease of communication and overall satisfaction judged by hospital staff [3]. The combination of text, photography, email and live video function has created the novel ability for immediate remote medical consultation, which for many hospital specialties is proving very valuable. General surgery trainees have reported the numerous advantages of the multifunctional smartphone for on-the-move decisionmaking and communication with colleagues. Dala-Ali et al. [4] discussed the benefits, for surgeons, of carrying a portable calendar, a full contact list, having instant access to hospital emails and the ability to make telephone calls. By their own admission, surgeons are ‘‘notoriously difficult to
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J. Maxillofac. Oral Surg.
contact’’, thus using a smartphone to combine many useful functions on one device has proven especially useful. Medical and surgical specialties alike are finding numerous uses for the advanced capabilities of smartphone technology, and their popularity continues to increase. As a direct consequence there has been an overwhelming increase in third party apps available for download, irrespective of the brand of smartphone platform used. Previous literature has discussed the use of smartphones and apps in many surgical specialities [4–6]. To date, no article has highlighted the merits or full scope of this technology within oral and maxillofacial surgery (OMFS). The aims of this paper are to investigate current patterns of smartphone and medical app use among British OMFS trainees, and inform the readership of the benefit of the smartphone within OMFS. We use the iPhone as an example platform to review a (non-exhaustive) collection of useful apps for the modern maxillofacial surgeon, discussing the specific clinical merits of the smartphone within OMFS.
Results We received responses from 51 Junior Trainees and 38 Specialty Trainees. At the time of distribution, 120 Specialty Trainees were registered with the Fellows in Training forum and 109 Junior Trainees were registered on the Junior Trainees Group forum. This equated to a response rate of 31.7 and 46.8 % respectively, comparable to other studies of a similar nature [5, 7]. Overall similar patterns of smartphone and app usage were displayed between the junior and senior trainee groups; as such data is grouped and presented together. In total 94.4 % (n = 84/89) of trainees owned a smartphone (92.2 % of Junior Trainees and 97.4 % of Specialty Trainees), with 60.7 % (n = 54/89) using the iPhone. Of those owning a smartphone, 89.3 % (n = 75/84) had downloaded medical related apps, with the majority owning between 1 and 5 medical apps, and very few owning more than 10 (Fig. 1). Frequency of use of medical apps during clinical activities is shown in Fig. 2.
iPhone Apps for the Maxillofacial Surgeon Methods Using an online survey tool (www.surveymonkey.com) we contacted British OMFS trainees via email, registered with the ‘Fellows in Training’ (registrar/specialty level trainees) and ‘Junior Trainee Group’ (open to OMFS senior house officers and interested medical and dental students) of the British Association of Oral and Maxillofacial Surgeons online forums. The survey [Appendix 1] was sent out twice, with a one-month window between each distribution. No honorarium was offered. The short questionnaire asked basic questions relating to smartphone and medical related app ownership, utilisation of the smartphone during clinical activities and which specific apps trainees found most useful. Questions were derived from previous literature [5, 7] and the personal experience of the authors. The survey was constructed by the two first authors, and reviewed by the remaining authors, with minor changes being made at this stage. Using both the data derived from the suggested useful apps section of our trainee survey, and from the authors collective personal experience, we explored useful and relevant apps using the Apple iPhone. In addition, the ‘power search’ function within the App Store was utilized, using keywords to search in different combinations such as ‘maxillofacial’, ‘maxfax’, ‘facial surgery’, ‘head and neck surgery’ among many others. Relevant apps were purchased and presented for the reader with their retail price, App Store star rating and target audience. We later review the apps by category based on content and function.
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To provide an educational resource for the readership we have constructed a list of reviewed iPhone apps relevant to the oral and maxillofacial surgeon. This list is derived from suggested useful apps from our trainee survey data and personal experience. We divide apps into one of six categories, based upon content and function (Table 1). Drug Dosing and Formulary Apps The British National Formulary (BNF) app and the BNF for Children app, both offer secure and uninterrupted information on prescribing, dispensing and administering medications. These apps are user friendly and well presented, however the main drawback is the requirement to
Fig. 1 Number of medical related apps owned by maxillofacial surgery trainees already owning a smartphone
J. Maxillofac. Oral Surg.
excellent drug formulary, together with additional features such as an ‘interaction checker’ and clinical calculators.
Logbook Apps
Fig. 2 Frequency of use of medical related apps by maxillofacial surgery trainees during clinical activities
pay the full app fee for every BNF update (information is updated biannually and annually respectively). Paeds ED is a paediatric medication dose calculator with the ability to select drug dose based on age or weight. This is a low cost, quick and simple-use app, which includes all medications relevant to paediatric maxillofacial surgery. As an alternative to the costly BNF app, Epocrates is a free app that is useful for all surgeons. It contains an
The eLogbook app has the useful feature of syncing directly with the Royal College of Surgeons of England eLogbook website (Fig. 3c). The app itself mimics the web based version but does require an annual subscription fee for website syncing capability. The use of the online Intercollegiate Surgical Curriculum Programme has been mandatory for surgical trainees on the new curriculum [8]. This is used as part of the Annual Review of Competence Progression where trainees have to demonstrate an up-todate and contemporaneous logbook [9]. The data is housed by the Royal College of Surgeons of Edinburgh, so that no patient identifiable data is kept on the smartphone. This application was co-written by a maxillofacial trainee and is increasingly used by all surgical trainees. iDoctor gives the surgeon a handheld logbook to record procedures, log patients seen, hours worked,
Table 1 iPhone apps listed within function based categories with cost, app store star rating and training grade target audience information displayed Category
App name
Cost
App store star rating
Training grade target audience
Drug doses and formulary apps
BNF
£29.99/$42.99/€33.99
No rating
All grades
BNF children
£39.99/$59.99/€44.99
No rating
All grades
Paeds ED lite
Free (Paeds ED £1.49)
4/5
All grades
Epocrates
Free (website registration required)
2.5/5
All grades
Logbook apps
Mobile elogbook
Free (annual subscription fee £4.99)
4/5
All grades
iDoctor
£6.99/$9.99/€7.99
4.5/5
All grades
Clinical and educational apps
iResus
Free
4/5
Junior-middle grade trainees
Snellen
Free
3/5
All grades
AO surgery reference
Free
5/5
Junior-middle grade trainees
Netters advanced head and neck flash cards
£27.99/$39.99/€31.99
2.5/5
Junior trainees
Oxford handbook of ENT and head and neck surgery
£34.99/€39.99
No rating
Junior trainees
Image viewing apps
Maxfax SHO
Free
4/5
Junior trainees
Mobile MIM
3/5
Middle-senior grades
OsiriX HD
Free ($1 per patients set of images) £20.99/$29.99/€23.99
No rating
Middle-senior grades
Literature search and journal apps
PubSearch
Free
3/5
All grades
NEJM this week
Free
3.5/5
All grades
National OMFS association apps
BAOMS
Free
3/5
All grades
AAOMS
Free
3/5
All grades
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J. Maxillofac. Oral Surg.
Fig. 3 Clockwise a–d—screenshots of reviewed apps. a Maxfax SHO app, b mobile MIM app, c mobile eLogbook app and d AO surgery reference app
education attended and consults given in a secure interface. The selling point for this app is its comprehensive scope of all working activities compared to other similar apps.
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Clinical and Educational Apps iResus offers up-to-date guidance from the Resuscitation Council (UK) for management of emergencies in and out
J. Maxillofac. Oral Surg.
of hospital. It is a free app that contains essential information for all physicians and surgeons alike. The real-time updates, algorithm approach, and clearly displayed drug doses make this a fantastic app. A simple yet useful app, iSnellen provides accurate bedside visual acuity recordings for quick and easy documentation. An invaluable tool for the OMFS surgeon to aid medico-legal documentation of orbital and zygomatic insults. AO Surgery Reference is a comprehensive resource of craniofacial and dentoalveolar surgery (Fig. 3d). It provides technical guidance on approaches, detailed procedures, quick-reference guides and literature search. It has an easy to navigate system which is laid out in a logical manner. Users can chose which area of the craniofacial skeleton they wish to review (skull base and cranial vault, midface, mandible and dentoalveolar trauma). They are then directed into teaching on common fracture patterns, how to manage them, surgical approaches and definitive management, with appropriate aftercare information. For the panicked trainee pre-theatre or for education and illustration to patients, Netters Advanced Head and Neck Flash Cards is a colourful informative app. It provides good content on embryology, development, head and neck anatomy and useful annotated CT imaging for the maxillofacial trainee and beyond. The Oxford Handbook of ENT and Head and Neck Surgery is a useful app for junior trainees. This resource offers some useful cross specialty topics on anatomy, examination and management options of ENT emergencies, parotid, salivary gland and sinus disease as well as head and neck cancer surgery. Maxfax SHO is a recently released free app useful for junior trainees new to OMFS (Fig. 3a). Currently the only OMFS-specific app in the market, with useful information on emergency and ward based management of all major scenarios, it also houses a useful contacts page for bleep numbers and hospital extensions. Image Viewing Apps OsiriX HD is an interactive visualisation programme designed for the display and analysis of medical images. It is compatible with any DICOM-compatible software including PACS servers. It comes at a cost, but is free to operate once synced with the computer or server. As an alternative to the above app, Mobile MIM is a free app, but charges $1 per patient’s set of images (Fig. 3b). Users upload images to a ‘cloud’ service (a web-based file storage service), which can then be accessed remotely on the iPhone or iPad. It has the benefit of being fully FDA approved to view diagnostic images, with accredited security features. These apps have the greatest potential for the enhancement of telemedicine via the virtual exchange
of medical images aiding learning and offsite management of patients. Literature Search and Journal Apps PubSearch is a simple search tool for all medical professionals enabling access to research articles indexed by PubMed (Medline) without the need for a PC. This serves as an excellent tool for all grades and specialties. Access to the free version requires an Institution or Library password, avoided by purchasing the PubSearch Plus version (£1.99). Although not specific to OMFS, the NEJM This Week app is the only medical journal of its kind available for iPhone. It offers the latest medical research findings, review articles and editorial opinion from The New England Journal of Medicine. OMFS Association Apps The BAOMS app is the official British association app. Currently this app only provides information on up and coming conferences and events which have BAOMS involvement. The potential scope for expansion, to access the members site and vote in BOAMS council elections via this route will no doubt be explored in the future. Also available is the American Association of Oral and Maxillofacial Surgeons App; this provides a news feed, events listing, and a product guide.
Discussion We provide evidence that the great majority of British maxillofacial surgery trainees own smartphones and regularly use apps to aid their clinical activities. Furthermore, these high levels of smartphone and app use within the British OMFS trainee community appears to correlate with similar trends in other surgical subspecialties [4] and among medical trainees [7]. Maxillofacial trainees are using smartphones to improve access to health information, notably clinical management or drug guidelines, with little use of more complex apps. This endorsement of new technology within OMFS is both encouraging and vital to our growth as a specialty. The remainder of this article will discuss the merits of the smartphone, its relevant clinical application and benefits specifically within OMFS. Above we have illustrated many examples of useful downloadable apps, which in themselves make the smartphone a beneficial device for a maxillofacial surgeon. Additional educational opportunities also exist through smartphone downloads such as scholarly podcasts and iTunes U. Below we discuss other
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J. Maxillofac. Oral Surg.
clinical uses of the smartphone’s enhanced functionality software. Access to Health Information
informed consent for any such procedure. Many hospital trusts already have in place strict policies to prevent the use of personal photography including mobile phones in the hospital and it is important to refer to these. Telecommunication
Smartphones have the ability to allow the clinician rapid access to healthcare information, either by utilising a downloaded medical app, opening a stored PDF or e-book within their personal library, or by searching the internet. Most smartphones also have the facility to create text documents for note taking, and having this information to hand when under pressure and on the move cannot be underestimated. A recent systematic review highlighted the valuable impact of smartphone use in patient care by providing ‘point of care’ assistance and allowing the clinician to consult the most recent clinical management guidelines ‘on-the-go’ [2]. A study by Lindquist et al. [10] also advocated the smartphone’s capability for immediate access to medical information, which is especially pertinent in time pressurised acute care scenarios. For the maxillofacial surgeon, corollaries can easily be drawn when managing patients with facial trauma and those acutely unwell with oro-facial sepsis, usually seen in the emergency department. One can instantly realise the benefits to the maxillofacial junior of having rapid access to drug dosages in combination with the use of the calculator function to compute drug values. Having immediate access to OMFS and emergency medicine e-books would also benefit juniors when dealing with new scenarios and procedures.
As previously discussed, telephone and email contact are invaluable to on-call specialties, particularly for specialties where the surgeon may be covering more than one site. Plastic surgeons have reported the valuable diagnostic use of the smartphone within their specialty as a tool for remote management of the extremity wound. A pilot study conducted by 3 plastic surgeons, reported success rates of 66–88 % in identifying gangrene, necrosis, erythema, and cellulitis using camera phone images. They were subsequently able to make remote treatment recommendations regarding whether to use antibiotics or to perform debridement from these photographs [13]. Armstrong et al. [15] describe the use of the iPhone FaceTime app during consultations and intra-operatively. This video-calling app was utilised by the authors to conduct real-time telemedicine clinic consultations and during surgery to seek advice from a colleague. In a similar article, in an OMFS setting, smartphone telemedicine has been described for ‘‘remote specialist consultation’’, utilising the ability to rapidly send digital images between surgeons [15, 16]. While enhanced telecommunication functions such as Facetime or Skype may prove useful, we advise adhering to local policy regarding video use in a clinical setting.
Teleradiology
Obstacles to Smartphone Use and Integration
Teleradiology is a simple but exciting concept very applicable to OMFS, which describes the ability to access radiographs remotely. Studies within cardiology [11] and stroke medicine [12] have provided excellent evidence of diagnostic accuracy when viewing radiographic images remotely on a handheld device. Common to both disciplines above and to OMFS are the problems of time-constrained management decisions combined with off-site seniors at night and on weekends. This ability to remotely visualise X-rays and CTs may be particularly pertinent to OMFS during emergency trauma scenarios.
As with all technological advances, concerns relating to clinical smartphone use have been raised [17]. The surgeon with a smartphone may encounter issues relating to professionalism, security and confidentiality. It opens the user up to indictments about being distracted at work, breaching data security, and even infection control issues of the device itself [18]. Worse still comes the potential problems associated with misplaced devices containing confidential patient details [17]. Technology is changing at such a rate that it is impossible to anticipate the future risks this technology may bring with regard to security. For many hospitals, the technological advances of the smartphone have come ahead of the security regulation that may govern its future use.
Photodocumentation For a maxillofacial surgeon, the ability to clearly record injures is crucial. Several papers have described novel uses of the smartphone camera feature [4, 13, 14]. A word of caution however for UK-based surgeons, please research and be mindful of local policy regarding clinical photography. In addition, one should always ensure to gain full
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Conclusion The smartphone has the ability to greatly influence the clinical activities of the modern oral and maxillofacial
J. Maxillofac. Oral Surg.
surgeon and further enhance patient care and safety [2]. However, our review of iPhone apps reveals only a small number currently available specific to OMFS. Nevertheless, the scope for growth and development is vast. Given the ease with which data on smartphones can be carried we should remain mindful of the ethical and legal manifestations of being mobile with such data and maintain our professions guidance on this matter [19]. With the exciting and evolving world of information technology merging with that of medicine, the clinician can use the smartphone to stay abreast of this modernising clinical environment. Medical apps are one example of this technological evolution, which is available to both clinicians and patients. As such, smartphones provide a promising new method of delivering and improving access to health information for maxillofacial surgeons. Acknowledgments No funding received or any financial gain made from any aspect of this article. Conflict of interest
None to declare.
Appendix 1 1. Do you own an iPhone or other smartphone? Please tick that which applies (if no please scroll to the bottom and click ‘complete survey’) a. b. c. d. e. f.
iPhone Google android Blackberry Nokia Other Does not own a smartphone
2. If yes, do you own medical related apps on your smartphone? a. b. c. d. e. f.
No Yes 1–5 Yes 6–10 Yes 11–15 Yes 16–20 Yes 20?
3. If yes, during clinical activities how often do you refer to the above apps? a. Never b. Rarely c. Sometimes d. Often e. Always
4. Please list specific apps that you find most useful: (free text entry box for data entry)
References 1. Devices 4 Limited. A survey of mobile phone usage by health professionals in the UK. London: Devices 4 Limited; December 2010. (http://www.d4.org.uk/research/) 2. Prgomet M, Georgiou A, Westbrook JI (2009) The impact of mobile handheld technology on hospital physicians’ work practices and patient care: a systematic review. J Am Med Inform Assoc 16(6):792–801 3. Wu RC (2010) The use of smartphones for clinical communication on internal medicine wards. J Hosp Med 5(9):553–559 4. Dala-Ali BM, Lloyd MA, Al-Abed Y (2011) The uses of the iPhone for surgeons. Surgeon 9(1):44–48 5. Ol F (2011) Smartphone apps for orthopaedic surgeons. Clin Orthop Relat Res 469(7):2042–2048 6. Kubben PL (2010) Neurosurgical apps for iPhone, iPod touch, iPad and Android. Surg Neurol Int 22(1):89 7. Payne KF, Wharrad HJ, Watts K (2012) Smartphone and medical related app use among medical students and junior doctors in the United Kingdom (UK): a regional survey. BMC Med Inform Dec Mak 12:121 8. Intercollegiate Surgical Curriculum Programme—www.iscp.ac. uk 9. http://surgicalcareers.rcseng.ac.uk/trainees/st3-and-beyond/arcp 10. Lindquist AM, Johansson PE, Petersson GI, Saveman BI, Nilsson GC (2008) The use of the personal digital assistant (PDA) among personnel and students in health care: a review. J Med Internet Res 10(4):e31 11. LaBounty T, Kim RJ, Lin FY, Budoff MJ, Weinsaft JW, Min JK (2010) Diagnostic accuracy of coronary computed tomography angiography as interpreted on a mobile handheld phone device. JACC Cardiovasc Imaging 3(5):482–490 12. Mitchell JR, Sharma P, Modi J, Simpson M, Thomas M, Hill MD, Goyal M (2011) A smartphone client-server teleradiology system for primary diagnosis of acute stroke. J Med Internet Res 13(2):e31 13. Hsich et al (2004) Teleconsultation with the mobile cameraphone in digital soft-tissue injury: a feasibility study. Plast Reconstr Surg 114(7):1776–1782 14. Teichman JC, Sher JH, Ahmed II (2011) From iPhone to eyePhone: a technique for photodocumentation. Can J Opthalmol 46(3):284–286 15. Armstrong DG, Giovinco N, Mills JL, Rogers LC (2011) Facetime for physicians: using real time mobile phone-based videoconferencing to augment diagnosis and care in telemedicine. Eplasty 3(11):e23 16. Aziz SR (2009) Telemedicine using smartphones for oral and maxillofacial surgery consultation, communication, and treatment planning. J Oral Maxillofac Surg 67(11):2505–2509 17. McAlearney AS, Schweikhart SB, Medow MA (2004) Doctors’ experience with handheld computers in clinical practice: qaulitative study. BMJ 328:1162 18. Brady RR, Verran J, Damani NN, Gibb AP (2009) Review of mobile communication devices as potential reservoirs of nosocomial pathogens. J Hosp Infect 71:295–300 19. (2006) Good medical practice—general medical council
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REVIEW PAPER
The Benefit of the Smartphone in Oral and Maxillofacial Surgery: Smartphone Use Among Maxillofacial Surgery Trainees and iPhone Apps for the Maxillofacial Surgeon Elinor Carey • Karl Frederick Braekkan Payne Nabeela Ahmed • Alexander Goodson
•
Received: 7 March 2013 / Accepted: 29 June 2013 Ó Association of Oral and Maxillofacial Surgeons of India 2013
Abstract The use of smartphones has soared among healthcare professionals in recent years, with estimated figures reporting that the majority of clinicians own and use smartphones in the workplace. Smartphones allow the clinician to carry textbooks in their pocket, write documents on the move and use email and internet to enhance productivity and clinical decision making. These advances in smartphone technology have enabled access to healthcare information for the clinician and transfer of data between team members, giving rise to the phenomenon of telemedicine. With the ability to instantly transfer clinical data to the off-site surgeon, combined with purpose-built medical apps, the smartphone is rapidly becoming an invaluable tool for the modern surgeon. Many studies have linked the benefits of smartphones and apps in other surgical specialities, but no article to date has highlighted the merits and full scope of this technology to the Oral and Maxillofacial Surgeon. We report that 94 % of British maxillofacial surgery trainees own a smartphone, with 61 % owning an iPhone. 89 % of trainees questioned had downloaded medical apps and used them regularly during clinical activities. We discuss the clinical application of the smartphone in the field of oral and maxillofacial surgery and review a list of useful and relevant apps for the modern maxillofacial surgeon using the iPhone as an example platform. Keywords Smartphone iPhone Application App Oral and maxillofacial surgery OMFS
E. Carey (&) K. F. B. Payne N. Ahmed A. Goodson Department of Oral & Maxillofacial Surgery, King’s College Hospital, London, UK e-mail: [email protected]
Introduction A smartphone is a category of mobile device that provides advanced capabilities beyond a typical mobile phone. Smartphones have a complete operating software system that provides a standardised interface and platform for application developers. They allow users to carry a mobile phone, games console, music player, camera, calendar and internet browser all in one small handheld device, with their limitations governed only by the types of applications (apps) downloaded onto them. The smartphone is now omnipresent among the general public and has rapidly permeated into healthcare, with recent studies estimating that over 80 % of doctors own a smartphone [1]. Evidence is growing to support the use of smartphones in the clinical setting, with benefits demonstrated as an electronic educational resource, in clinical decision making support and in the prevention of medication errors [2]. As an enhanced communication tool, studies have reported that smartphones were strongly preferred over any other form of hospital colleague–colleague communication. Improvements were seen in efficiency, ease of communication and overall satisfaction judged by hospital staff [3]. The combination of text, photography, email and live video function has created the novel ability for immediate remote medical consultation, which for many hospital specialties is proving very valuable. General surgery trainees have reported the numerous advantages of the multifunctional smartphone for on-the-move decisionmaking and communication with colleagues. Dala-Ali et al. [4] discussed the benefits, for surgeons, of carrying a portable calendar, a full contact list, having instant access to hospital emails and the ability to make telephone calls. By their own admission, surgeons are ‘‘notoriously difficult to
123
J. Maxillofac. Oral Surg.
contact’’, thus using a smartphone to combine many useful functions on one device has proven especially useful. Medical and surgical specialties alike are finding numerous uses for the advanced capabilities of smartphone technology, and their popularity continues to increase. As a direct consequence there has been an overwhelming increase in third party apps available for download, irrespective of the brand of smartphone platform used. Previous literature has discussed the use of smartphones and apps in many surgical specialities [4–6]. To date, no article has highlighted the merits or full scope of this technology within oral and maxillofacial surgery (OMFS). The aims of this paper are to investigate current patterns of smartphone and medical app use among British OMFS trainees, and inform the readership of the benefit of the smartphone within OMFS. We use the iPhone as an example platform to review a (non-exhaustive) collection of useful apps for the modern maxillofacial surgeon, discussing the specific clinical merits of the smartphone within OMFS.
Results We received responses from 51 Junior Trainees and 38 Specialty Trainees. At the time of distribution, 120 Specialty Trainees were registered with the Fellows in Training forum and 109 Junior Trainees were registered on the Junior Trainees Group forum. This equated to a response rate of 31.7 and 46.8 % respectively, comparable to other studies of a similar nature [5, 7]. Overall similar patterns of smartphone and app usage were displayed between the junior and senior trainee groups; as such data is grouped and presented together. In total 94.4 % (n = 84/89) of trainees owned a smartphone (92.2 % of Junior Trainees and 97.4 % of Specialty Trainees), with 60.7 % (n = 54/89) using the iPhone. Of those owning a smartphone, 89.3 % (n = 75/84) had downloaded medical related apps, with the majority owning between 1 and 5 medical apps, and very few owning more than 10 (Fig. 1). Frequency of use of medical apps during clinical activities is shown in Fig. 2.
iPhone Apps for the Maxillofacial Surgeon Methods Using an online survey tool (www.surveymonkey.com) we contacted British OMFS trainees via email, registered with the ‘Fellows in Training’ (registrar/specialty level trainees) and ‘Junior Trainee Group’ (open to OMFS senior house officers and interested medical and dental students) of the British Association of Oral and Maxillofacial Surgeons online forums. The survey [Appendix 1] was sent out twice, with a one-month window between each distribution. No honorarium was offered. The short questionnaire asked basic questions relating to smartphone and medical related app ownership, utilisation of the smartphone during clinical activities and which specific apps trainees found most useful. Questions were derived from previous literature [5, 7] and the personal experience of the authors. The survey was constructed by the two first authors, and reviewed by the remaining authors, with minor changes being made at this stage. Using both the data derived from the suggested useful apps section of our trainee survey, and from the authors collective personal experience, we explored useful and relevant apps using the Apple iPhone. In addition, the ‘power search’ function within the App Store was utilized, using keywords to search in different combinations such as ‘maxillofacial’, ‘maxfax’, ‘facial surgery’, ‘head and neck surgery’ among many others. Relevant apps were purchased and presented for the reader with their retail price, App Store star rating and target audience. We later review the apps by category based on content and function.
123
To provide an educational resource for the readership we have constructed a list of reviewed iPhone apps relevant to the oral and maxillofacial surgeon. This list is derived from suggested useful apps from our trainee survey data and personal experience. We divide apps into one of six categories, based upon content and function (Table 1). Drug Dosing and Formulary Apps The British National Formulary (BNF) app and the BNF for Children app, both offer secure and uninterrupted information on prescribing, dispensing and administering medications. These apps are user friendly and well presented, however the main drawback is the requirement to
Fig. 1 Number of medical related apps owned by maxillofacial surgery trainees already owning a smartphone
J. Maxillofac. Oral Surg.
excellent drug formulary, together with additional features such as an ‘interaction checker’ and clinical calculators.
Logbook Apps
Fig. 2 Frequency of use of medical related apps by maxillofacial surgery trainees during clinical activities
pay the full app fee for every BNF update (information is updated biannually and annually respectively). Paeds ED is a paediatric medication dose calculator with the ability to select drug dose based on age or weight. This is a low cost, quick and simple-use app, which includes all medications relevant to paediatric maxillofacial surgery. As an alternative to the costly BNF app, Epocrates is a free app that is useful for all surgeons. It contains an
The eLogbook app has the useful feature of syncing directly with the Royal College of Surgeons of England eLogbook website (Fig. 3c). The app itself mimics the web based version but does require an annual subscription fee for website syncing capability. The use of the online Intercollegiate Surgical Curriculum Programme has been mandatory for surgical trainees on the new curriculum [8]. This is used as part of the Annual Review of Competence Progression where trainees have to demonstrate an up-todate and contemporaneous logbook [9]. The data is housed by the Royal College of Surgeons of Edinburgh, so that no patient identifiable data is kept on the smartphone. This application was co-written by a maxillofacial trainee and is increasingly used by all surgical trainees. iDoctor gives the surgeon a handheld logbook to record procedures, log patients seen, hours worked,
Table 1 iPhone apps listed within function based categories with cost, app store star rating and training grade target audience information displayed Category
App name
Cost
App store star rating
Training grade target audience
Drug doses and formulary apps
BNF
£29.99/$42.99/€33.99
No rating
All grades
BNF children
£39.99/$59.99/€44.99
No rating
All grades
Paeds ED lite
Free (Paeds ED £1.49)
4/5
All grades
Epocrates
Free (website registration required)
2.5/5
All grades
Logbook apps
Mobile elogbook
Free (annual subscription fee £4.99)
4/5
All grades
iDoctor
£6.99/$9.99/€7.99
4.5/5
All grades
Clinical and educational apps
iResus
Free
4/5
Junior-middle grade trainees
Snellen
Free
3/5
All grades
AO surgery reference
Free
5/5
Junior-middle grade trainees
Netters advanced head and neck flash cards
£27.99/$39.99/€31.99
2.5/5
Junior trainees
Oxford handbook of ENT and head and neck surgery
£34.99/€39.99
No rating
Junior trainees
Image viewing apps
Maxfax SHO
Free
4/5
Junior trainees
Mobile MIM
3/5
Middle-senior grades
OsiriX HD
Free ($1 per patients set of images) £20.99/$29.99/€23.99
No rating
Middle-senior grades
Literature search and journal apps
PubSearch
Free
3/5
All grades
NEJM this week
Free
3.5/5
All grades
National OMFS association apps
BAOMS
Free
3/5
All grades
AAOMS
Free
3/5
All grades
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Fig. 3 Clockwise a–d—screenshots of reviewed apps. a Maxfax SHO app, b mobile MIM app, c mobile eLogbook app and d AO surgery reference app
education attended and consults given in a secure interface. The selling point for this app is its comprehensive scope of all working activities compared to other similar apps.
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Clinical and Educational Apps iResus offers up-to-date guidance from the Resuscitation Council (UK) for management of emergencies in and out
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of hospital. It is a free app that contains essential information for all physicians and surgeons alike. The real-time updates, algorithm approach, and clearly displayed drug doses make this a fantastic app. A simple yet useful app, iSnellen provides accurate bedside visual acuity recordings for quick and easy documentation. An invaluable tool for the OMFS surgeon to aid medico-legal documentation of orbital and zygomatic insults. AO Surgery Reference is a comprehensive resource of craniofacial and dentoalveolar surgery (Fig. 3d). It provides technical guidance on approaches, detailed procedures, quick-reference guides and literature search. It has an easy to navigate system which is laid out in a logical manner. Users can chose which area of the craniofacial skeleton they wish to review (skull base and cranial vault, midface, mandible and dentoalveolar trauma). They are then directed into teaching on common fracture patterns, how to manage them, surgical approaches and definitive management, with appropriate aftercare information. For the panicked trainee pre-theatre or for education and illustration to patients, Netters Advanced Head and Neck Flash Cards is a colourful informative app. It provides good content on embryology, development, head and neck anatomy and useful annotated CT imaging for the maxillofacial trainee and beyond. The Oxford Handbook of ENT and Head and Neck Surgery is a useful app for junior trainees. This resource offers some useful cross specialty topics on anatomy, examination and management options of ENT emergencies, parotid, salivary gland and sinus disease as well as head and neck cancer surgery. Maxfax SHO is a recently released free app useful for junior trainees new to OMFS (Fig. 3a). Currently the only OMFS-specific app in the market, with useful information on emergency and ward based management of all major scenarios, it also houses a useful contacts page for bleep numbers and hospital extensions. Image Viewing Apps OsiriX HD is an interactive visualisation programme designed for the display and analysis of medical images. It is compatible with any DICOM-compatible software including PACS servers. It comes at a cost, but is free to operate once synced with the computer or server. As an alternative to the above app, Mobile MIM is a free app, but charges $1 per patient’s set of images (Fig. 3b). Users upload images to a ‘cloud’ service (a web-based file storage service), which can then be accessed remotely on the iPhone or iPad. It has the benefit of being fully FDA approved to view diagnostic images, with accredited security features. These apps have the greatest potential for the enhancement of telemedicine via the virtual exchange
of medical images aiding learning and offsite management of patients. Literature Search and Journal Apps PubSearch is a simple search tool for all medical professionals enabling access to research articles indexed by PubMed (Medline) without the need for a PC. This serves as an excellent tool for all grades and specialties. Access to the free version requires an Institution or Library password, avoided by purchasing the PubSearch Plus version (£1.99). Although not specific to OMFS, the NEJM This Week app is the only medical journal of its kind available for iPhone. It offers the latest medical research findings, review articles and editorial opinion from The New England Journal of Medicine. OMFS Association Apps The BAOMS app is the official British association app. Currently this app only provides information on up and coming conferences and events which have BAOMS involvement. The potential scope for expansion, to access the members site and vote in BOAMS council elections via this route will no doubt be explored in the future. Also available is the American Association of Oral and Maxillofacial Surgeons App; this provides a news feed, events listing, and a product guide.
Discussion We provide evidence that the great majority of British maxillofacial surgery trainees own smartphones and regularly use apps to aid their clinical activities. Furthermore, these high levels of smartphone and app use within the British OMFS trainee community appears to correlate with similar trends in other surgical subspecialties [4] and among medical trainees [7]. Maxillofacial trainees are using smartphones to improve access to health information, notably clinical management or drug guidelines, with little use of more complex apps. This endorsement of new technology within OMFS is both encouraging and vital to our growth as a specialty. The remainder of this article will discuss the merits of the smartphone, its relevant clinical application and benefits specifically within OMFS. Above we have illustrated many examples of useful downloadable apps, which in themselves make the smartphone a beneficial device for a maxillofacial surgeon. Additional educational opportunities also exist through smartphone downloads such as scholarly podcasts and iTunes U. Below we discuss other
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clinical uses of the smartphone’s enhanced functionality software. Access to Health Information
informed consent for any such procedure. Many hospital trusts already have in place strict policies to prevent the use of personal photography including mobile phones in the hospital and it is important to refer to these. Telecommunication
Smartphones have the ability to allow the clinician rapid access to healthcare information, either by utilising a downloaded medical app, opening a stored PDF or e-book within their personal library, or by searching the internet. Most smartphones also have the facility to create text documents for note taking, and having this information to hand when under pressure and on the move cannot be underestimated. A recent systematic review highlighted the valuable impact of smartphone use in patient care by providing ‘point of care’ assistance and allowing the clinician to consult the most recent clinical management guidelines ‘on-the-go’ [2]. A study by Lindquist et al. [10] also advocated the smartphone’s capability for immediate access to medical information, which is especially pertinent in time pressurised acute care scenarios. For the maxillofacial surgeon, corollaries can easily be drawn when managing patients with facial trauma and those acutely unwell with oro-facial sepsis, usually seen in the emergency department. One can instantly realise the benefits to the maxillofacial junior of having rapid access to drug dosages in combination with the use of the calculator function to compute drug values. Having immediate access to OMFS and emergency medicine e-books would also benefit juniors when dealing with new scenarios and procedures.
As previously discussed, telephone and email contact are invaluable to on-call specialties, particularly for specialties where the surgeon may be covering more than one site. Plastic surgeons have reported the valuable diagnostic use of the smartphone within their specialty as a tool for remote management of the extremity wound. A pilot study conducted by 3 plastic surgeons, reported success rates of 66–88 % in identifying gangrene, necrosis, erythema, and cellulitis using camera phone images. They were subsequently able to make remote treatment recommendations regarding whether to use antibiotics or to perform debridement from these photographs [13]. Armstrong et al. [15] describe the use of the iPhone FaceTime app during consultations and intra-operatively. This video-calling app was utilised by the authors to conduct real-time telemedicine clinic consultations and during surgery to seek advice from a colleague. In a similar article, in an OMFS setting, smartphone telemedicine has been described for ‘‘remote specialist consultation’’, utilising the ability to rapidly send digital images between surgeons [15, 16]. While enhanced telecommunication functions such as Facetime or Skype may prove useful, we advise adhering to local policy regarding video use in a clinical setting.
Teleradiology
Obstacles to Smartphone Use and Integration
Teleradiology is a simple but exciting concept very applicable to OMFS, which describes the ability to access radiographs remotely. Studies within cardiology [11] and stroke medicine [12] have provided excellent evidence of diagnostic accuracy when viewing radiographic images remotely on a handheld device. Common to both disciplines above and to OMFS are the problems of time-constrained management decisions combined with off-site seniors at night and on weekends. This ability to remotely visualise X-rays and CTs may be particularly pertinent to OMFS during emergency trauma scenarios.
As with all technological advances, concerns relating to clinical smartphone use have been raised [17]. The surgeon with a smartphone may encounter issues relating to professionalism, security and confidentiality. It opens the user up to indictments about being distracted at work, breaching data security, and even infection control issues of the device itself [18]. Worse still comes the potential problems associated with misplaced devices containing confidential patient details [17]. Technology is changing at such a rate that it is impossible to anticipate the future risks this technology may bring with regard to security. For many hospitals, the technological advances of the smartphone have come ahead of the security regulation that may govern its future use.
Photodocumentation For a maxillofacial surgeon, the ability to clearly record injures is crucial. Several papers have described novel uses of the smartphone camera feature [4, 13, 14]. A word of caution however for UK-based surgeons, please research and be mindful of local policy regarding clinical photography. In addition, one should always ensure to gain full
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Conclusion The smartphone has the ability to greatly influence the clinical activities of the modern oral and maxillofacial
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surgeon and further enhance patient care and safety [2]. However, our review of iPhone apps reveals only a small number currently available specific to OMFS. Nevertheless, the scope for growth and development is vast. Given the ease with which data on smartphones can be carried we should remain mindful of the ethical and legal manifestations of being mobile with such data and maintain our professions guidance on this matter [19]. With the exciting and evolving world of information technology merging with that of medicine, the clinician can use the smartphone to stay abreast of this modernising clinical environment. Medical apps are one example of this technological evolution, which is available to both clinicians and patients. As such, smartphones provide a promising new method of delivering and improving access to health information for maxillofacial surgeons. Acknowledgments No funding received or any financial gain made from any aspect of this article. Conflict of interest
None to declare.
Appendix 1 1. Do you own an iPhone or other smartphone? Please tick that which applies (if no please scroll to the bottom and click ‘complete survey’) a. b. c. d. e. f.
iPhone Google android Blackberry Nokia Other Does not own a smartphone
2. If yes, do you own medical related apps on your smartphone? a. b. c. d. e. f.
No Yes 1–5 Yes 6–10 Yes 11–15 Yes 16–20 Yes 20?
3. If yes, during clinical activities how often do you refer to the above apps? a. Never b. Rarely c. Sometimes d. Often e. Always
4. Please list specific apps that you find most useful: (free text entry box for data entry)
References 1. Devices 4 Limited. A survey of mobile phone usage by health professionals in the UK. London: Devices 4 Limited; December 2010. (http://www.d4.org.uk/research/) 2. Prgomet M, Georgiou A, Westbrook JI (2009) The impact of mobile handheld technology on hospital physicians’ work practices and patient care: a systematic review. J Am Med Inform Assoc 16(6):792–801 3. Wu RC (2010) The use of smartphones for clinical communication on internal medicine wards. J Hosp Med 5(9):553–559 4. Dala-Ali BM, Lloyd MA, Al-Abed Y (2011) The uses of the iPhone for surgeons. Surgeon 9(1):44–48 5. Ol F (2011) Smartphone apps for orthopaedic surgeons. Clin Orthop Relat Res 469(7):2042–2048 6. Kubben PL (2010) Neurosurgical apps for iPhone, iPod touch, iPad and Android. Surg Neurol Int 22(1):89 7. Payne KF, Wharrad HJ, Watts K (2012) Smartphone and medical related app use among medical students and junior doctors in the United Kingdom (UK): a regional survey. BMC Med Inform Dec Mak 12:121 8. Intercollegiate Surgical Curriculum Programme—www.iscp.ac. uk 9. http://surgicalcareers.rcseng.ac.uk/trainees/st3-and-beyond/arcp 10. Lindquist AM, Johansson PE, Petersson GI, Saveman BI, Nilsson GC (2008) The use of the personal digital assistant (PDA) among personnel and students in health care: a review. J Med Internet Res 10(4):e31 11. LaBounty T, Kim RJ, Lin FY, Budoff MJ, Weinsaft JW, Min JK (2010) Diagnostic accuracy of coronary computed tomography angiography as interpreted on a mobile handheld phone device. JACC Cardiovasc Imaging 3(5):482–490 12. Mitchell JR, Sharma P, Modi J, Simpson M, Thomas M, Hill MD, Goyal M (2011) A smartphone client-server teleradiology system for primary diagnosis of acute stroke. J Med Internet Res 13(2):e31 13. Hsich et al (2004) Teleconsultation with the mobile cameraphone in digital soft-tissue injury: a feasibility study. Plast Reconstr Surg 114(7):1776–1782 14. Teichman JC, Sher JH, Ahmed II (2011) From iPhone to eyePhone: a technique for photodocumentation. Can J Opthalmol 46(3):284–286 15. Armstrong DG, Giovinco N, Mills JL, Rogers LC (2011) Facetime for physicians: using real time mobile phone-based videoconferencing to augment diagnosis and care in telemedicine. Eplasty 3(11):e23 16. Aziz SR (2009) Telemedicine using smartphones for oral and maxillofacial surgery consultation, communication, and treatment planning. J Oral Maxillofac Surg 67(11):2505–2509 17. McAlearney AS, Schweikhart SB, Medow MA (2004) Doctors’ experience with handheld computers in clinical practice: qaulitative study. BMJ 328:1162 18. Brady RR, Verran J, Damani NN, Gibb AP (2009) Review of mobile communication devices as potential reservoirs of nosocomial pathogens. J Hosp Infect 71:295–300 19. (2006) Good medical practice—general medical council
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